Dr. Bosshardt's Blog

Breast implant information for patients- updated October 2016

The decision to have a breast augmentation is a major one with life-long consequences. Please be sure you understand this operation well and have all of your questions answered before proceeding. Once surgery is done, it can never be totally undone.

 

The only way to add meaningful volume or fullness to your breasts is to use breast implants. You cannot do exercises, take pills, use creams, or use “vacuum pumps” to accomplish this goal!! Some surgeons are using fat grafts to enlarge breasts. This procedure has not been widely adopted because there are still lingering questions about the long term effects of injecting one’s own fat into the breasts. The process usually requires more than one operation and rarely increases breast size more than ½ - 1 cup size. I do not feel confident enough in this procedure to offer it to my patients.

 

The following information is being provided to you in order to ensure that you are fully informed about breast augmentation. It is a comprehensive summary of this very popular plastic surgical procedure. Together with your consultation with me, the information contained herein should allow you to make an informed decision about whether or not this operation is for you.

 

Our facility-

            The surgery is done in our office which includes a state-licensed ambulatory surgery center. I am not aware of any other plastic surgery office in Central Florida that contains such a surgical center. Our operating room is subject to the same inspections and staffing requirements as those of hospitals. We have all the necessary staffing, equipment, and resources to perform surgery with the safety our patients deserve, and to handle any emergencies. I recommend doing the surgery here because we can better preserve confidentiality, our staff are very familiar with operations we do, and our facility costs are significantly lower than at other ASC’s or hospital operating rooms. I have admitting privileges at Florida Hospital Waterman, Leesburg Regional Medical Center, and South Lake Hospital if you wish to go elsewhere for surgery, but the costs will be greater. In the event of a problem, we can transfer patients immediately across the street to Waterman Hospital. This has never been necessary following a breast augmentation. Because this is a state licensed ambulatory facility, we cannot keep patients overnight. In over 27 years, I have never seen a patient who was unable to go straight home after their breast augmentation.

 

Anesthesia-

            I perform breast augmentation under general anesthesia. Another option is using local anesthesia with heavy sedation but I do not like that. I do not believe sedation is any safer and it presents potential problems, such as patients feeling pain, becoming aware, or squirming while undergoing surgery, making the procedure more

                       

 

difficult to perform. Many practices that do office-based breast augmentation perform this surgery under local anesthesia with sedation only because they are not accredited to do general anesthesia. We do not have this limitation. I have never had a single patient experience any complication from anesthesia during, or after, a breast augmentation.

 

Incisions-

            Several incisions are used for breast augmentation. They are along the edge of the areola (the colored skin around the nipple), in the crease under the breast, the axilla (armpit), and the umbilicus (belly button). The last one is known as the TUBA (Trans-Umbilical Breast Augmentation). It is rarely done and I feel it is adds risks and almost no benefits other than avoiding a scar under the breast. I don’t feel that the axillary approach or TUBA have any significant advantages over the others and choose not to offer then at this time. Of the first two, I prefer an incision in the crease under the breast. My aesthetic sense is that the nipple and areola are the visual focal point of the female breast and our eyes are drawn to this area. I do not like to put a scar there. In this approach, no breast tissue has to be cut, in contrast to the areolar incision, which also carries a greater chance of causing loss of feeling to the nipple area. For saline implants, the incision is usually and inch or less on length. For gel implants the incision will be 2-3 inches long.

 

Implant position-

            Once an incision is made, a space must be created for the implant. This space is called a “pocket” and can be placed either under or over your pectoralis muscle, a large, flat triangular muscle which sits under the breasts. When I examine you, I have you contract this muscle to assess its position and degree of development. Most breast augmentations are done with the implant placed beneath this muscle. Advantages of this position are several. With more tissue over the implant, it less prone to be seen or felt through the skin. Under-the-muscle implants are less likely to experience tightening of the scar tissue that naturally forms around the implant. This is called capsular contracture and will be explained below. Under-the-muscle position makes it a little easier to obtain acceptable mammograms later. For some patients, such as those with very developed muscles or some breast sagging, it may be better to place the implant on top of the muscle. The pectoralis muscle must be partially released from it’s attachments to the ribs in under-the-muscle placement. This should result in no appreciable loss of upper body strength or arm motion. With under muscle implants, breasts will usually demonstrate some change in shape when the muscle is contracted. This ranges from minimal to very noticeable. It does not cause any problem beyond this and only rarely justifies attempts at correction. Most breast implants done in the U.S. today are done under the muscle.

 

 

The Implants-

You have the choice of silicone gel or saline implants for their surgery. I still feel that for most women, saline implants (filled with sterile, salt water) provide a result that is on par with silicone gel implants and these are my “go to” implants for most patients unless I feel that the gel implants are better for a specific individual. Saline implants are excellent implants and provide wonderful results for most patients. One advantage to saline is that if the implants ever rupture or leak, the saline is harmlessly absorbed by your tissues and eliminated. Replacing a leaking implant is quite simple and easy to do. Women with unusually thin skin and minimal breast tissue, may benefit from the gel implants because they tend to produce less visible rippling. This fact may be more important when the implants are under thinner tissue. The new gel implants have a more viscous gel that will not run, so leaks should not be as messy as in the past. One of the potential problems with gel implants is difficulty detecting leaks and it is recommended by the FDA and implant manufacturers that women get an MRI three years after implantation and every two years after that to check for leaks. This is a suggestion not a requirement. The cost of an MRI is around $1000 and insurance will not cover this examination for the purpose of diagnosing a leak in a cosmetic implant.

 

            Saline implants come in several styles. There are round/smooth, round/textured, anatomical/smooth, and anatomical/textured. I do not use textured or anatomically shaped saline implants because they are more prone to leaking and malposition. When I use saline implants I always use round, smooth implants.

 

There are several styles of gel implants available now. We offer two different gel implants which will cover any patient’s needs. One is a smooth, round gel implant. I tend to recommend these when patients have very little breast tissue of their own or when they want large implants. The other is the newest implant type, a “form stable” implant, which is popularly called the “gummy bear” implants because they have a gel that is more solid and will not run. Form stable implants are all anatomically shaped and textured. They are best for women with small, non-saggy breasts who do not want a large implant. All gel implants require a larger incision (2-3 inches long versus 1 inch for saline) to insert and are much more expensive than saline implants. I cannot offer gel implants to patients 22 years or younger at the time of their surgery.

 

How to choose an implant size-

The most important decision to be made, which will determine your results, and satisfaction, is the size of implant chosen for you. There is no formula, computer program, or other method which is guaranteed to perfectly predict what an implant will do for you or give you the exact implant size that will perfectly satisfy you. Putting implants in your bra will not tell you what these will do for you inside your breasts. For nearly 27 years I have determined the implant size for each patient by using implant sizers in surgery. I can place these in the pocket and inflate them to any size I wish, to see how the breasts look with an implant actually in them. I encourage you to tell me what your goals are. Unless, you wish otherwise, I try to produce a result that will look natural, look well proportioned to your body, have normal sensitivity, and feel as soft and normal as possible. I have had very few patients ever return desiring a larger or smaller implant than they received. Patients who choose their own implants are often disappointed because of picking one that is too small. If you are unhappy with your implant size, I will recommend that you live with them for one year. Some patients simply take longer to adjust to their new appearance. If, at the end of that time, you still wish for a bigger, or smaller, implant, I will offer to exchange your implants for new ones at a discounted fee. This offer is good for one year from the date of your surgery.

 

Bra cup size-

Please understand that there is no uniform standard that defines an A, B, C, or D cup bra. The style of bra, type of material, manufacturer, and personal patient preferences all influence the cup size someone wears. Victoria’s Secret, for example, makes their bras small so that their customers will have a larger cup size, usually by one or even two sizes than when they purchase bras from other manufacturers. This is why using cup size to describe breasts is very imprecise and I have not found it very useful. While I will do my best to get you the cup size you wish, my primary goal is not a specific cup size but, rather, a happy patient. If you are happy with your results, then cup size is secondary. If you desire something more conservative, or “showy”, please let me know. As long as it is not medically inappropriate, or dangerous, I will do my utmost to help you achieve your goals.

 

Recovery and convalescence from surgery-

            Some postoperative discomfort is to be expected from all surgery and breast augmentation is no exception. I will inject a long acting anesthetic around your breasts. You will receive medications for pain and this will usually keep you fairly comfortable. Most patients are off of the prescription pain medications within a few days. Only a few will need a refill. You should remain physically quiet for the first 5-6 days. After I see you for your first postoperative visit, if you are doing well, I will no longer restrict your activities. This means that you can resume doing whatever you can do comfortably. Just use common sense and don’t overdo things like exercise, etc. for a week or two. You should be back up to 100% within 4 weeks. In three months you should see your final result. I will usually take my final photographs 6 months after surgery, at your final visit.  

 

Photographs-

            I will take photographs of your breasts before surgery and at your final visit. This is to help plan your surgery and assess the final results. They do not show your face and will never be shown to anyone without your express, written permission. You are welcome to have copies of your before and after pictures if you wish. I may ask you for your permission to use your photographs in our practice and this would be greatly appreciated but you should feel no obligation to allow their use if this makes you uncomfortable.

 

Breast augmentation; the upside-

            Breast augmentation has a very high patient satisfaction rate, one of the highest for any cosmetic surgery. In studies of patients who have had breast implants for over ten years, the satisfaction level is consistently greater than 90%. It is very uncommon for women to be dissatisfied with the results of their surgery. Even those patients who have complications, or less than perfect results, tend to prefer their breasts with implants over how they were before surgery. My goal is that six months after your surgery you will be very happy with your decision to have this surgery.

 

Breast augmentation; the downside or risks/complications/limitations-

 

            Breast augmentation, like all surgical procedures, carries risks, and complications can occur. Every effort is made to prevent complications but no operation, and no surgeon, or patient, is perfect. Every procedure has limitations in what it can accomplish. Below is a listing of the more common risks and limitations.

           

Capsular contracture- All breasts will form a layer of scar tissue around the implant. This scar is called a capsule. If the capsule shrinks (contracts), and/or thickens, it can begin to squeeze the implant and this can make the breast feel hard. Severe contracture can distort the breast shape or even be painful. No one knows exactly why a few patients do this. Some researchers feel that it may be due to bacteria you’re your skin colonizing the surface of the implant. I take measures in surgery to try to prevent this but it is not possible to do this perfectly. Contracture to some degree occurs in between 3 and 5 % of patients and it is not possible to predict who these will be. I will ask you to do several things after your surgery to prevent contractures. This may include taking vitamin E orally, massaging your breasts, and wearing a compression bra or strap. Not all surgeons do all these things.  It is very important to follow my instructions carefully, but even diligent adherence to this program does not guarantee that a contracture cannot not occur. If a contracture occurs severe enough to produce an unacceptable outcome, correction will require revision surgery. There will be an additional cost for this revision which will mainly cover the expenses of surgery. In addition to this surgery, I may use additional measures including long term antibiotics. If you experience capsular contracture after such a revision, I do not usually recommend more surgery to try to fix this as I feel the chance of success at that point is very low. If a revision does not resolve the problem, I will offer to remove your implants at no additional cost to you. Over my career, very few patients have done this.

 

            Capsule stretching- Less common than contracture, in some patients, the implant pocket may gradually stretch. This can result in too much visible movement of the implants. When you lay down, the implants may shift too far to the side. When you sit up, the implant may sit too low on the chest, making the nipple look too high on the breast. This problem is difficult to correct and requires surgery to tighten the implant pocket with stitches. Correction sometimes requires the use of expensive materials to reinforce the suturing of the pocket. There will be a fee for this type of corrective surgery just as for a revision as noted above.  Successful correction of this condition cannot be guaranteed.

 

            Stretch marks- Young patients, patients who have never been pregnant, and those with small breasts and tight skin are at risk of stretch marks from having implants inserted. Some people are simply genetically predisposed to stretch marks. There is no way to predict who will get them. They are not common but when they do occur, they are permanent as there is no way to eliminate stretch marks.

           

Leakage- Saline implants have a risk of leaking of between 5 and 9% in the first 10 years. After that, the failure rate increases by 1% per year. Your implants carry a lifetime replacement warranty. If they leak or fail for any reason, you will be given 2 new implants by the manufacturer. For the first 10 years after surgery, the manufacturer will provide a stipend for the cost of replacing one implant ($1200). You can obtain $2400 of coverage, for replacement of 2 implants by paying the maker $100 within 45 days after your surgery (I strongly recommend this). You will receive a brochure explaining this. Leakage of a saline implant is harmless, as noted above. Some leaks occur overnight. Others may take weeks to become obvious. All leaks eventually become obvious. The presence of capsular contracture increases the risk of implant failure. Gel implants have a leak rate of between 0.5-2.7% over 3-4 years. Precise numbers are difficult to come by since gel leaks can go undetected for years. The new, form stable (gummy bear) implants do not leak but can experience fracture of the gel material that may affect the look of your breasts

 

            Visible rippling and wrinkling- Implants cannot perfectly mimic the breast tissue that you do not have naturally. Saline implants, as they settle, can produce visible and/or palpable ripples and winkles that can be seen on the surface of the breasts. This is more likely the larger the implant is relative to the natural breast. Rippling is less common with gel implants and least with the form stable implants. Contracture of the pocket makes rippling and wrinkling more prominent. You must understand that breast augmentation is an unnatural process that tries to produce a natural result. A few patients may get that perfect result which looks and feels entirely natural. Most patients get a very nice result, but one that is not 100% perfect. Rippling and wrinkling only rarely cause significant dissatisfaction with the procedure.

 

            Abnormal movement of the implants- because implants are not the same as your natural breast tissue, the way they move in your breasts will not exactly mimic breast tissue. You may see the implants shift as you change position. This is more likely in patients with very thin breast tissue and skin. If your implants are under the muscle, when you forcefully contract the muscle, the inner, lower area of the breasts will probably flatten and the implant will visibly move. This is only rarely objectionable. I can sometimes minimize this but it requires additional release of the muscle. Unless you are an elite, competitive athlete, you should not notice any change in your athletic abilities after breast augmentation. For elite athletes, or those with highly developed muscles, I may recommend putting the implants above the muscle and using gel implants.

 

            Loss of nipple/areola sensitivity- 90% of women will not lose any of the natural sensitivity of the breast, especially the nipple/areola area. Most patients will have some numbness in the breast skin, most often in the lower half of the breast. This usually resolves in a couple of months. Hypersensitivity of the nipples can occur and this usually resolves more rapidly. In a few patients, loss of some degree of normal sensitivity may be permanent, and in a rare patient, the nipples may be quite numb. So far, no patient of mine has ever expressed regret over having the surgery because of loss of feeling. Removing the implants is not expected to reverse loss of sensitivity.

           

Calcifications in the breast tissue- over years, calcium deposits may form in the tissue around your implants or in the scar tissue around the implants and this can appear on a mammogram. This is a natural response to the presence of implants in some women.The calcium deposits are harmless but can make interpretation of mammograms difficult. Rarely, clarifying the nature of calcium depostis may require a biopsy of the breast. Any surgery on your breasts carries the risk of harming the implants in some way.

 

            Breast implants and cancer- At this time, it is almost universally accepted that women with breast implants do not have an increased chance of developing breast cancer. Numerous studies over the past 30 years, of tens of thousands of women, have failed to demonstrate any link between breast implant surgery and increased risk of breast cancer. In 2011, FDA reported a possible connection between breast implants and an extremely rare form of lymphoma of the breast. This is hundreds of times less common than breast cancer is for women without implants. So far the problem appears to be exclusively connected to textured implants and in nearly 85% of cases where the implant has been identified, it has been from a single manufacturer, Allergan. I do not use Allergan textured implants in my practice. The FDA is aware of this concern and the problem is being intensively monitored. So far, the FDA has not felt this problem justifies any change in the status of breast implants as an approved medical device.

 

            Breast implants and illness- There has been a small and very vocal group of women who have blamed their implants on nearly unlimited range of medical problems from hair loss to hangnails. The common factor has been they became sick when they had implant placed and got better after they were removed. Studies have not demonstrated any connection between breast implants and any disorder of the immune system or known illness. Nevertheless, some women continue to make this claim and some go so far as to state that surgeons and manufacturers are suppressing information regarding this to hide the fact that implants are somehow “toxic”. I do not believe this. In 27 years of practice I have not seen anyone who had an illness that seemed likely to be due to their implants. I do feel that there might be- and I stress “might”- a small population of women who are unusually susceptible to the presence of silicone and may react in undesirable ways. This is just conjecture and has not been proven to occur. There have been reports of implants with mold or bacteria in or on them and it is theorized that this may be the source of women's complaints. This has not been definitively shown to occur and, if it does, it seems to be relatively rare. It is important to realize that we know more about implants now than we did 30 years ago and will know more in the future than we know now. Women desiring implants must understand and accept that there are some aspects of this surgery that we do not have answers to. If you cannot accept this, perhaps you should consider not having the surgery.

 

            Interfering with mammograms- implants do block x-rays and produce a shadow on mammograms. To get around this, mammogram techniques are modified for women with implants. A displacement technique is used to push the implants out of the way, and additional views are taken. Most, but not all, of the breast tissue can be seen. It is theoretically possible that a small lump might be missed, and if this lump were cancerous, this could result in a delay in diagnosis and treatment. Studies have compared breast cancer patients who had breast implant surgery with those who never had implants. No statistical difference has been found in the results of the cancer treatment between the two groups. Capsular contracture, by making the breasts difficult or impossible to compress, can compromise mammography. Breasts that stay soft can be examined by mammography more effectively. This is why I feel compliance with the  program of breast massage, taking vitamin E, and using a compression garment to help keep your breasts soft is so important early on after surgery. Follow your primary care provider’s recommendations for obtaining screening mammograms.

 

            Complications common to all surgery- Breast augmentation also has many complications in common with other surgeries. These include, but are not limited to, such things as infection, bleeding, poor quality scars, delayed healing, injury to structures in or around the area of surgery, complications related to anesthesia, and complications which can be serious, or even life threatening, such as blood clots in the legs or lungs, heart attack, stroke, pneumonia, and more. The likelihood of any of these happening to you is less than 1%. There are many more potential complications of surgery, enough to fill a book, but these are so uncommon that they should not be of concern. 

 

            Summary of complications- While complications from breast augmentation are rare, they can and do occur. The only way to completely eliminate the potential for complications is to avoid having breast implant surgery.

 

 

Future surgery-

I do not feel that it is realistic to expect a breast implant to be in your body for decades without a significant chance of a leak or some other problem at some time in the distant future. It is not true that breast implants have to be replaced on some regular schedule, such as every ten or fifteen years. It is highly likely, however, that at some time in the future you will need or desire another operation on your breasts as a result of implant surgery. The most common reasons would be to replace a leaking implant, remove them altogether at some time, exchange them ( for something larger, smaller, or, perhaps, a newer, better implant than is available today), correct a late occurring contracture (this is rare but can happen), perform a breast lift for sagging, or some other procedure. Because breast augmentation is a cosmetic procedure, any surgery related to this will probably be regarded as cosmetic by most insurance companies and, therefore, not covered by insurance.

                                                    

What will your breasts look like years from now?-

Many things will affect the look of your breasts over the years. Pregnancy (if applicable to you), weight loss or gain, health issues, habits (exercise, sleep, diet, smoking, drinking, etc.), genetic makeup, and the manner in which your body ages, to name a few. It is therefore impossible to predict how your breasts will look years from now. After implant surgery, your breasts will be heavier and gravity will affect them more. I recommend that you not go braless routinely. Beyond your skin and some fine ligaments, both of which will stretch with time, a bra is the only support your breasts have. Hopefully, your breasts will look nice for many years.

 

Smoking and breast augmentation-

            Besides being one of the worst things for your health, smoking can have very significant adverse effects on the results of breast augmentation. It has been my experience that patients exposed to cigarette smoke during the critical period before and after surgery are much more prone to developing capsular contracture, which I discussed above. This holds for those who smoke themselves, and those who inhale much second hand smoke. If you smoke around the critical period around your surgery, it may affect your result.  Smoking should be stopped for 6 weeks before surgery and full 3 months afterwards. Ideally, you should abstained from for a stop altogether! If you smoke and develop a tight, hard breast, I will not offer a revision attempt unless you stop.

 

Guarantees-  

There are innumerable variables and intangible factors that can affect the outcome of any operation. Many of these are out of my control, and yours. You must understand, and accept, this small degree of uncertainty if you wish to undergo a breast augmentation. If you decide to move forward with the surgery I guarantee that when I do the surgery, I will bring to bear all of my skill and experience on that day to provide you with the best result that I can. Beyond this no surgeon can promise more. I hope that you will be able to say that you are happy with the result of this surgery. My goal is for nothing less than for every patient to be able to do this.

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